Golden Rose Care Center

During an interview on 9/11/2025 at 11:33 PM, the GACH Social Worker (GSW) stated Resident 1 was ready for discharge on [DATE]. GSW stated GACH Case Manager called the facility on 9/6/2025 and informed the MA that Resident 1 was ready to return to the facility on 9/6/2025 but was made aware that the facility does not have an available bed for Resident 1.

During a concurrent record review of the facility form titled, admission / Discharge to/ from Report, from 9/1/2025 to 9/10/2025 and interview with Registered Nurse (RN1) on 9/11/2025 at 1:39 PM, RN 1 stated the admission / Discharge to/ from Report indicated Resident 1 was discharged to GACH on 9/2/2025. RN1 also stated the facility did not follow the physician's order for 7-day bed hold because the facility had admitted a new resident in Resident 1's bed.

RN 1 stated this was the reason Resident 1 was still in GACH and could not be readmitted back to the facility.

During an interview on 9/11/2025 at 2 PM with the Administrator (ADM), the ADM stated the bed reserved for Resident 1 was no longer available because it was given to a new resident on 9/5/2025. ADM also stated that Resident 1's bed should have been reserved for Resident 1 for 7 days, which was from 9/3/2025 to 9/9/2025.

The ADM also stated the purpose of the bed hold was to reserve the same bed for 7 days to ensure the residents would have a homelike environment when ready to return to the facility anytime within that period.

The ADM further stated if the facility had saved Resident 1's bed, Resident 1 would have gone back to the same room on the day the resident was ready to return to the facility.

During a record review of the facility's Policy & Procedure (P&P) titled, Bed Hold, revised 9/1/2023, the P&P indicated, upon admission, the facility advises residents/ resident's representative in writing that the facility has a bed hold policy and will hold the resident's bed for up to 7 days if the resident is transferred to a general acute hospital.

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